Healthcare Provider Details

I. General information

NPI: 1255609905
Provider Name (Legal Business Name): RAVENSWOOD PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 W WILSON AVE STE 102
CHICAGO IL
60640-5255
US

IV. Provider business mailing address

1945 W WILSON AVE STE 102
CHICAGO IL
60640-5255
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-8048
  • Fax: 773-561-8084
Mailing address:
  • Phone: 773-561-8048
  • Fax: 773-561-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054017816
License Number StateIL

VIII. Authorized Official

Name: SAMEH ATTIA
Title or Position: PIC
Credential:
Phone: 773-612-2517